Table 5.

Barriers MAs Face When Trying to Improve Population Health Measures

Barrier	Illustrative Quotation
Time pressure including inability to work overtime	“There’s a lot of [population health] questions and there’s a lot of pressure for us to do a lot within a certain time frame, and so I think asking [all] the questions is kind of out of the question. It’s too much to do.” (MA 1, FG 4) “We can’t have overtime, but we can’t do our job. We can’t do everything we need to do in the amount of the time we have.” (MA 3, FG 8) “I have my little [population health] folders at my desk, all paper, all wanting to be done.” (MA 2, FG 5)
Poor patient compliance (multifactorial)	“They go home, they’re the ones that have to take that pill, go to the pharmacy and get it. Pay for it. A lot of our patients, it’s ‘why aren’t you taking your diabetes med?’ ‘I can’t afford it.’ … It’s heartbreaking.” (MA 2, FG 9) “I think there’s a patient assumption that they assume that the doctor is going to always take care of them and do those refills, but the system’s not set up for that.” (MA 1, FG 7)
Patient declines care	“Sometimes patients don’t want to do colonoscopies and even patients that are due for colonoscopy will be like, ‘I don’t care, I’m not going to do that till the day I die.’ So that is challenging.” (MA 1, FG 3) An exchange from FG 8: “I know it gets frustrating when someone’s coming in and they’re sick and we’re like, ‘Let me go over the depression questionnaire with you.’” (MA 4) “They need a refuse button because I’ve had a patient that refuses to answer questions.” (MA 2) “They do.” (MA 4)
Lack of physician follow-through	“Everybody’s doctor’s different. Some doctors are very good at being more meticulous in their record keeping and making sure things are ordered and stuff, where other doctors don’t order things as well and whatnot. … You may work twice as hard but your doctor didn’t make the metrics, so you’re not getting anything, yet you’re working just as hard as someone else.” (MA 6, FG 2)
Poorly designed electronic health record	“I think it’s remembering when the MAs are doing the remaining intake to get to that e-cigarette area because it’s a separate screen so you have to remember to take that extra step because vaping is such a new thing.” (MA 9, FG 1) “We scan that sucker [vaccination] it should autofill, without a doubt. That just doesn’t make any sense to me. Same with even just logging on … why does his [primary care physician] name not autofill? I use it 99% of the time?” (MA 3, FG 9)
Inability to adequately address a positive depression screen	Facilitator [follow-up question regarding the depression screen]: “Does anybody start crying?” An exchange from FG 2: “Almost every other patient … They’re coming in for like a toe, foot problem. You’re asking them some depression questions and they break down.” (MA 7) “That’s why it’s hard for the doctors too. When we were trying to add it to the workflow, it was hard for them, because they were like, ‘Okay. We’re here for foot pain and now we’re talking about depression.’ And of course, in all of this it expanded more than the 15 to the 30 or 40 [minutes].” (MA 4) An exchange from FG 9: “You have no choice but to stare at a computer because you’ve got to hit all these dots, rather than, you know, sit there and when they’re crying at you …” (MA 2) “And you only have that short window to get it done.” (MA 4) “‘Stop crying for just a minute.’” (MA 2) “And you have to hurry because the doctor’s on your butt.” (MA 4)
Reluctance to irritate patient	“I personally don’t like quizzing because if someone asked me every time I saw a provider, I would be annoyed, so I try to make a mark of that, like ‘when’s the last time I asked them?’ so I know if they’re not a generally depressed person so I’m not bothering them.” (MA 4, FG 7) “It is a lot of extra work, and we’re not harassing people, but sometimes it feels like we’re harassing them, making sure they’re doing what they need to do, but in the end it is saving [the health system] money. It is saving patients hospital visits. It is saving ER [emergency room visits]. So it is making a difference. It doesn’t always feel like it.” (MA 2, FG 7)
Frequent role switching	“It’s very important that same MA continues doing the [population health list] work for it, especially on admin time. That way you know where you left off, because someone else touches it, it ends up you have to start from the beginning to understand.” (MA 2, FG 5)

FG = focus group; MA = medical assistant.